Individual
ELYSE WAHLQUIST VAN WAGENEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MA CCC SLP
Contact information
Practice address
11287 NW STATE ROAD 20, BRISTOL, FL 32321-3414
(850) 694-4420
Mailing address
11287 NW STATE ROAD 20, BRISTOL, FL 32321-3414
(850) 694-4420
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
SA17587
FL
235Z00000X
Speech-Language Pathologist
SLPCF000042
DC
Other
Enumeration date
05/23/2019
Last updated
12/02/2024
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